Research Potential
CPOE systems afford opportunities to delve further into clinical research and QI projects.
The flow of care in hospitals is inextricably linked with writing orders—for medications, tests, consultations, or interventional care processes. “Interfacing with CPOEs, therefore, can help influence the way care is practiced more broadly for our patients,” says Dr. Karson. “By embedding rules and decision support elements within our CPOE systems, we can improve the quality and safety of the care that we provide.”
The effect of CPOE on ICU patient care was highlighted in a 2005 study conducted by intensivist Stephen P. Hoffmann, MD, medical director, ICU, and associate professor of medicine at Ohio State University Medical Center, Columbus, and his colleagues. The team compared orders for ICU care before and after modification of a CPOE system and found that use of higher-efficiency CPOE order paths led to significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management.3
Paul D. Hain, MD, interim chief of staff and director of the Pediatric Hospitalist Program at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., and his colleagues at Vanderbilt University’s School of Medicine have been able to use their institution’s advanced CPOE to increase adherence to evidence-based treatments.
With the help of IT support staff, Dr. Hain inserted a pop-up window into the CPOE to remind providers that bronchodilators (albuterol) and steroids are ineffective for the treatment of bronchiolitis. Working with a third-year medical student, Ryan Bailey, Dr. Hain compared orders for these treatments in the years preceding installation of his pop-up reminder with those afterward. There was a significant drop in the non-evidence-based treatments, he notes, based on the installation of the pop-up window. “The reminder actually worked!” he exclaims. “It got people to stop using inappropriate therapies.”
This type of quality improvement, says Dr. Hain, is good for the hospital, for the hospitalists, and for their non-hospitalist colleagues. “This type of reminder allows us to share evidence-based guidelines with other admitting physicians in real time, and it appears to be a much more effective way to communicate information, as evidenced by our success in decreasing non-evidence-based treatments for bronchiolitis,” he asserts. The pop-up window includes a link to the treatment guidelines, so it also offers users an educational opportunity.
Close the Loop
Dr. Hoffmann and others caution about the limitations of using CPOE data. Most CPOE systems, notes Dr. Hoffmann, do not have a way of capturing whether an order or intervention was actually carried out.
“With CPOE, you can get a very good handle on how many order sets for processes of care have been ordered, but it doesn’t complete the loop—it doesn’t tell you whether that process of care happened once it has been ordered,” Dr. Hoffman says. “If you use the CPOE data set alone and stop there, the process is going to be fraught with unreliable information.”
CPOE can be a good tool for organizing clinical improvement projects but may not be the perfect tool for verifying outcomes of the order set. This was underscored by a project Dr. Hoffmann and his team conducted in collaboration with the University HealthSystem Consortium (UHC) on ventilator-associated pneumonia (VAP). The team wrote policy and processes based on current evidence for preventing VAP—such as raising the heads of patients’ beds to 30 degrees when they are mechanically ventilated—and created a flowchart of those processes. The aim of the project was to tie these care processes to the order for a ventilator, so that each time one was ordered, the other care items were bundled with it to trigger changes at the bedside. Now, it won’t be possible for a provider to order a ventilator without at least reviewing and ordering the additional care processes.